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Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Sunday, October 19, 2014

There has been a lot written about Ebola lately,
and lots of talk about it, and fear about it, in the halls of the hospital and
clinics where I work, and I would guess lots of other places also. I don’t have
any expertise in Ebola, and don’t claim to know what should have been done, or
what “we” should be doing going forward, but it is clear that there have been mistakes,
or at least major miscalculations, made by the WHO and the CDC and other
government agencies. Some of this may be the result of cuts in funding over the
last many years, some the result of emphasis on bioterrorism rather than the
impact of infectious agents that get transmitted the regular way (“Failures
of Competence”, Joe Nocera, October 18, 2014) but has been both sobering as
well as a vehicle for administration opponents to attack it. Of course, the
attacks may be justified, but there is no reason to think a previous
administration would have done better.

First, it is critical to point out that the real problem,
suffering, and crisis is in West Africa, in Liberia and Sierra Leone, and
Guinea. In countries with little infrastructure and few resources and in the
cases of the first two, relatively recent histories of devastating civil wars. The
concern about Ebola in the US (so far two home-grown cases, both in nurses who
cared for the Liberian man in Texas) needs to be seen in that context. Those
countries that are severely affected need major resources, both human and
financial, and need them fast. An excellent video analysis of the issues was
recently done by Laurie Garrett on a webinar called “The
Ebola crisis: the best and worst case scenarios from here”. Thankfully, there
is some recognition of the need in these countries among those who are seeking
to make political hay of this crisis; my own Senator Jerry Moran has joined
others, particularly other Republicans, in calling for closing off flights from
the affected countries, but proposes to exempt health workers. Of course, this
misses the fact that it is easier to screen folks coming from those countries
than people who first travel to other countries and then fly to the US.

What does interest me about the whole discussion in this
country around Ebola is the degree to which it illustrates two common flaws in
the way people think about problems. One, obviously at play in the case of
Ebola, is the fear of the new, unfamiliar, and scary, especially when hyped up
by the media. Thus, for example, the reluctance of both patients and staff
(encouraged by their families) to come to work in our clinic during the period
that a patient at our hospital was being ruled out for Ebola (he didn’t end up
having it), even though it is in a separate building and the patient was three
layers of isolation deep. This fear is stoked by events such as the revelation
that the second nurse to come down with Ebola had been allowed to fly from
Texas to Ohio and back on a commercial airliner (although it could just as well
be cited as evidence that anyone,
working in a hospital or not, might be at risk).

The second is that people often find it easier to worry
about, to get worked up about, problems that they are at low risk for but that
they cannot do anything about, even when they are not doing what they could do
to prevent problems for which they are at much greater risk. I have written in
the past about a prototypical patient obsessed by breast cancer, a condition
for which she was in fact at no increased risk, who was not doing anything
about problems she could act on such as uncontrolled hypertension, cigarette smoking,
and unprotected sex with multiple partners. Indeed, my point was that if she was worried about those last three,
people would expect her to do
something about them since she could – she could take blood pressure
medication, stop or cut down on her smoking, and use protection when having
sex. But those might be hard. Worrying
about breast cancer, something that there was nothing she herself could do to
prevent (doctors could order
mammograms, at too young an age and far too frequently, but she wouldn’t have to do anything) was,
in this sense, easier. Both of these logical flaws were highlighted by comments
from the chief medical officer of my hospital, early in the isolation of the
possible Ebola patient: “If 20,000 people were dying of Ebola there would be
riots in the streets. But every year an average of 22,000 Americans die of
influenza, and people still don’t get their flu shots”.

This selective concern is a form of determinism, the topic
addressed by Konika Banerjee and Paul Bloom in “Does
everything happen for a reason?” in the NY
Times, October 19, 2014. They discuss the idea of fate, that things happen
that were destined to happen, that experiences of adversity which
coincidentally lead to positive outcomes (the man hospitalized for injuries as
a result of the 2013 Boston Marathon bombings who falls in love with and
marries his nurse) are “meant to be”. They note that while this is most common
in people who are religious and believe that God determines everything, it is
still a very common belief among atheists. It is an attractive idea, but it is
a mis-reading of chance. That is, people pay attention when things seem to fortuitously
happen, or a coincidence facilitates something you wanted to happen. (E.g., yesterday
morning I heard a part of a 1981 song on the oldies station but couldn’t
remember its name; amazingly, when I turned the station back on in the evening,
it was playing again! Fated? No, just Rick Springfield’s “Jesse’s Girl”.) We
forget how often things do not happen,
but remember when they do. Banerjee and Bloom write:

Not
everyone would go as far as the atheist Richard Dawkins, who has written that
the universe exhibits “precisely the properties we should expect if there is,
at bottom, no design, no purpose, no evil, and no good, nothing but blind,
pitiless indifference.”

Deists, like Thomas Jefferson I heard yesterday (also on the
radio, but NPR this time), believed that the world was so ordered that there
must be a creator, although they rejected the detailed instructions that many
of their contemporaries took from the Bible or other religious texts. However,
the random nature of events, as suggested by Dawkins or by Stephen Jay Gould (“Full
House: The Spread of Excellence from Plato to Darwin”) accounts for these just
as well.

The same issue of the Times
contains a more medically related piece, “Why
doctors need stories”, by Peter D. Kramer. I like stories, and I use them a
lot (see above for a couple); they make things come alive, tie abstract events
to actual lives, create examples in the experience of individual people of
phenomena that are harder to understand when we look only at populations. But
they can be misused; my story about the woman who was more worried about breast
cancer than her smoking or high blood pressure is meant to be an example of how
people can choose which facts they believe and which they ignore. It doesn’t
prove anything, certainly not that most people act this way, or don’t. It does
(I hope) get your attention. We have to be careful how stories are used; “I
knew someone who had an abnormal Pap smear and she didn’t do anything and it
went away”, while consistent with our most current knowledge about the early
course of abnormal Pap smears in young women, is not a valid argument for you to not do anything. Stories tell
what they tell; the lessons learned and conclusions reached are up to us.

Banerjee and Bloom end their piece:

If
there is such a thing as divine justice or karmic retribution, the world we
live in is not the place to find it. Instead, the events of human life unfold
in a fair and just manner only when individuals and society work hard to make
this happen. We should resist our natural urge to think otherwise.

And, no matter what we think about Ebola, we should get our
flu shots.